Periodic Reporting for period 1 - PREGAFTERPL (Couples' experience and need for medical care and psychosocial support during pregnancy after prior pregnancy loss)
Reporting period: 2021-08-16 to 2023-08-15
Pregnancy loss (PL) occurs in about 25% of pregnancies. PL is the spontaneous loss of a pregnancy before approximately 22 weeks and “early” PL is before the end of the first trimester (12 weeks). Previous research shows that women and their partners are unhappy with existing treatment and care they receive after PL and wish for more information, follow-up and support. A new pregnancy after PL can be stressful for women and their partners given they fear another PL. Unfortunately, support interventions targeted to pregnancy after PL are virtually non-existent. We need to understand when women and partners are most in need of targeted care in order to promote overall well-being and best outcomes for couples and their future child.
To address this issue, the EU-funded PREGAFTERPL project conducted a qualitative longitudinal study with pregnant couples with one or two prior PLs to improve our understanding of couples’ experiences and needs for medical care, psychosocial support and follow-up during a pregnancy after PL(s). Couples were interviewed after a positive pregnancy test and once in each trimester to also shed light on common reactions and ways of coping during pregnancy after PL. The findings were integrated into a new support intervention co-developed with stakeholders and patients and informed the development of workshops for clinicians to inform and enhance care provided to these couples.
The study was conducted in Denmark, which has a public health care system. Standard pregnancy care includes an ultrasound scan at 12 and 20 weeks. Antenatal care is provided by midwives with an intake appointment around week 15 with the majority of contact with midwife in the second half of pregnancy (20+ weeks). For those who can afford it, individual scans can be purchased at private clinics.
In summary, results from PREGAFTERPL show an early PL creates an increased need for monitoring and care in a subsequent pregnancy. These findings underscore that PL care should extend into a new early pregnancy after one or two PL(s). Our qualitative longitudinal study highlights a gap in pregnancy care for those with a history of one to two PLs in the first months of a new pregnancy when both partners are anxious about another PL. The study showed that after the 20-week mark, couples felt safety in the antenatal care program and more secure about the pregnancy as the weeks progressed. Couples wished for sensitivity, empathy and understanding from health care professionals about their history of PL. They wished for more information and support about common reactions and coping strategies. We used a three-stage intervention development model informed by the Medical Research Council’s guidance to co-produce and prototype test an information and support tool intervention for pregnancy after PL with stakeholders and patients (women and partners) to meet the need identified by couples in the qualitative longitudinal study. We also developed two workshops and an educational video to educate health care professionals about these couples’ needs and recommendations for enhanced care.
To address this issue, the EU-funded PREGAFTERPL project conducted a qualitative longitudinal study with pregnant couples with one or two prior PLs to improve our understanding of couples’ experiences and needs for medical care, psychosocial support and follow-up during a pregnancy after PL(s). Couples were interviewed after a positive pregnancy test and once in each trimester to also shed light on common reactions and ways of coping during pregnancy after PL. The findings were integrated into a new support intervention co-developed with stakeholders and patients and informed the development of workshops for clinicians to inform and enhance care provided to these couples.
The study was conducted in Denmark, which has a public health care system. Standard pregnancy care includes an ultrasound scan at 12 and 20 weeks. Antenatal care is provided by midwives with an intake appointment around week 15 with the majority of contact with midwife in the second half of pregnancy (20+ weeks). For those who can afford it, individual scans can be purchased at private clinics.
In summary, results from PREGAFTERPL show an early PL creates an increased need for monitoring and care in a subsequent pregnancy. These findings underscore that PL care should extend into a new early pregnancy after one or two PL(s). Our qualitative longitudinal study highlights a gap in pregnancy care for those with a history of one to two PLs in the first months of a new pregnancy when both partners are anxious about another PL. The study showed that after the 20-week mark, couples felt safety in the antenatal care program and more secure about the pregnancy as the weeks progressed. Couples wished for sensitivity, empathy and understanding from health care professionals about their history of PL. They wished for more information and support about common reactions and coping strategies. We used a three-stage intervention development model informed by the Medical Research Council’s guidance to co-produce and prototype test an information and support tool intervention for pregnancy after PL with stakeholders and patients (women and partners) to meet the need identified by couples in the qualitative longitudinal study. We also developed two workshops and an educational video to educate health care professionals about these couples’ needs and recommendations for enhanced care.
In our qualitative longitudinal study we conducted interviews with 15 couples recruited from the Copenhagen Pregnancy Loss Cohort to investigate their experience and needs for medical care and support across the three trimesters of pregnancy. Interviews were conducted with couples together after the first pregnancy test and once in each trimester. Our thematic analysis showed that for couples there were two phases of pregnancy: the first 20 weeks with a “scary” gap in pregnancy care, and the second 20 weeks with a sense of safety in the existing antenatal program. These findings highlighted a gap in the care needs in the first half of pregnancy when couples were particularly anxious, worried and distressed about experiencing another PL and had less access to standardized care. Findings showed that both partners expressed a high degree of worry and anxiety about the pregnancy, particularly in the early months. Partners wished to be more involved in care and to receive information about how to support their partner and to cope with their own worries. The findings challenge the assumption that because PL is common, couples should “just try again” which minimizes the psychological and physical impact of this event.
In the intervention development phase of the project, we used a three-stage to co-produce and prototype test an intervention with stakeholders and patients. We created a stakeholder group of multidisciplinary experts to consult on the development of the intervention. Two focus groups were held with patients (women and partners) for input into the content of the intervention and to provide feedback on the early prototype. Finally, an online survey was developed to assess patient views on the acceptability of the intervention. The focus group and online survey data showed that the intervention was acceptable, useful and relevant. Patient feedback was integrated into the final versions of the intervention. For example, we developed a separate tool for women and for partners to meet their unique needs. The intervention is available online and paper format and is being integrated into care provided at Hvidovre Hospital through the Copenhagen Pregnancy Loss research project. A manuscript on this process is forthcoming.
PREGAFTERPL findings have been presented at the European Society of Human Reproduction and Embryology, The Nordic Fertility Society, The European Preconception Health and Care conference. Two conference presentations are upcoming at the European Public Health conference 2024. Our first open access article is: Koert E et al. (2023). 'You're never pregnant in the same way again': prior early pregnancy loss influences need for health care and support in subsequent pregnancy. Human Reproduction Open. 2023(3):hoad032.
Workshops for clinicians have been provided at the Danish Fertility Society and Midwives Association annual meetings. An educational video is available online and will be distributed to the Danish Society of Obstetrics and Gynecologists.
Our exploitation strategies included presenting the findings to health care professionals, community stakeholders and general public and providing patient information workshops. The information tools can be integrated into a larger web-based tool for PL support planned by the Copenhagen Pregnancy Loss research group. We plan a grant application to test the feasibility, implementation and evaluation of the information tool intervention into an early pregnancy unit setting.
In the intervention development phase of the project, we used a three-stage to co-produce and prototype test an intervention with stakeholders and patients. We created a stakeholder group of multidisciplinary experts to consult on the development of the intervention. Two focus groups were held with patients (women and partners) for input into the content of the intervention and to provide feedback on the early prototype. Finally, an online survey was developed to assess patient views on the acceptability of the intervention. The focus group and online survey data showed that the intervention was acceptable, useful and relevant. Patient feedback was integrated into the final versions of the intervention. For example, we developed a separate tool for women and for partners to meet their unique needs. The intervention is available online and paper format and is being integrated into care provided at Hvidovre Hospital through the Copenhagen Pregnancy Loss research project. A manuscript on this process is forthcoming.
PREGAFTERPL findings have been presented at the European Society of Human Reproduction and Embryology, The Nordic Fertility Society, The European Preconception Health and Care conference. Two conference presentations are upcoming at the European Public Health conference 2024. Our first open access article is: Koert E et al. (2023). 'You're never pregnant in the same way again': prior early pregnancy loss influences need for health care and support in subsequent pregnancy. Human Reproduction Open. 2023(3):hoad032.
Workshops for clinicians have been provided at the Danish Fertility Society and Midwives Association annual meetings. An educational video is available online and will be distributed to the Danish Society of Obstetrics and Gynecologists.
Our exploitation strategies included presenting the findings to health care professionals, community stakeholders and general public and providing patient information workshops. The information tools can be integrated into a larger web-based tool for PL support planned by the Copenhagen Pregnancy Loss research group. We plan a grant application to test the feasibility, implementation and evaluation of the information tool intervention into an early pregnancy unit setting.
Findings of the PREGAFTERPL have had societal impacts on a regional, national and international level. The information tool intervention is available publicly for patients. Workshop training for clinicians has been provided on a national level. A conference presentation has been given at an international conference for a large group of gynecologists and fertility clinicians.
As we continue to disseminate and exploit our findings, we expect to further collaborate with the interdisciplinary Copenhagen Pregnancy Loss research group and contribute to their mission of improving clinical care after PL and reducing the negative psychological burden of PL. Future studies using Danish registries will also examine if long term occurrence of mental health issues after PL will be reduced after introducing the intervention including an economic evaluation.
As we continue to disseminate and exploit our findings, we expect to further collaborate with the interdisciplinary Copenhagen Pregnancy Loss research group and contribute to their mission of improving clinical care after PL and reducing the negative psychological burden of PL. Future studies using Danish registries will also examine if long term occurrence of mental health issues after PL will be reduced after introducing the intervention including an economic evaluation.